Healthcare Provider Details

I. General information

NPI: 1174699011
Provider Name (Legal Business Name): CANDICE M. MOORE OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 INTERSTATE 55 NORTH SUITE 291, HIGHLAND VILLAGE
JACKSON MS
39211
US

IV. Provider business mailing address

766 CLEARMONT DR
PEARL MS
39208-6261
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax: 601-362-0870
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1713
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: